Paying for performance to improve the delivery of health interventions in low- and middle-income countries (Review)

Abstract

Background There is a growing interest in paying for performance as a means to align the incentives of health workers and health providers with public health goals. While the volume of schemes implementing paying for performance has increased over the last decade, rigorous evidence on the effectiveness of these strategies in improving health care and health, particularly in low- and middle-income countries is lacking. This is an update on the 2012 review on this topic, which had identified a limited evidence base from which to draw conclusions.

Objectives To summarise the current evidence for the effects of paying for performance on the provision of health care and health outcomes in low and middle-income settings.

Search methods We searched more than 15 databases in 2018, including the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 3), the Cochrane EFective Practice and Organisation of Care (EPOC) Group Specialised Register (10 April 2018), MEDLINE, Ovid (1946 to Present) (searched 10 April 2018), EMBASE, Ovid (10 April 2018), WHOLIS, VHL (April 2018), CINAHL, EBSCOhost (1981 to present) (April 2018), Global Health, Ovid (27 April 2018), The Grey Literature Report (June 2018) and OpenGrey (June 2018). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. Relevant studies identified from rerunning the strategies in 2020 are placed under Studies awaiting classification.

Search methods We searched more than 15 databases in 2018, including the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 3), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (10 April 2018), MEDLINE, Ovid (1946 to Present) (searched 10 April 2018), EMBASE, Ovid (10 April 2018), WHOLIS, VHL (April 2018), CINAHL, EBSCOhost (1981 to present) (April 2018), Global Health, Ovid (27 April 2018), The Grey Literature Report (June 2018) and OpenGrey (June 2018). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. Relevant studies identified from rerunning the strategies in 2020 are placed under Studies awaiting classification.

Selection criteria We included randomised or quasi-randomized trials, controlled before-after studies or interrupted time series studies conducted in low or middle-income countries (as defined by the World Bank in 2018). Pay for performance refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: changes in targeted measures of provider performance, such as the delivery or utilisation of healthcare services, or patient outcomes, unintended effects and/or changes in resource use.

Data collection and analysis We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations and analyses and outcome reporting, meta-analysis was deemed inappropriate. Within the review, we note the range of effects associated with P4P against each outcome of interest.

Main results We included 59 studies in this update. Evaluations were predominantly controlled before and after studies or quasi randomized trials, however we also identified cluster randomized trials and interrupted time-series studies. Studies focused on a wide range of paying for performance (P4P) interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. The majority of assessed schemes were funded by the World Bank. Targeted services varied, however most of the interventions focused on indicators related to reproductive, maternal and child health. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities. The assessment of P4P was predominantly at health facility level, though districts and other levels were also involved. The majority of studies assessed the effects of paying for performance (P4P) against a status quo control (49 studies); however, some studies focused on assessing effects against comparator interventions (predominantly enhanced financing intended to match P4P funds, based on 17 studies). Four studies reported on intervention effects against both comparator and status quo. In relation to utilization and service delivery outcomes, we identify inconsistent effects overall. P4P may have slight positive impacts on the majority of health outcomes appraised against a pure control or standard care; however, when compared against other interventions such as enhanced financing, limited to no impacts were identifiable. P4P probably increases quality of care overall, particularly when directly targeted by scheme designs, and may have positive impacts on the availability of medicines, equipment and infrastructure. However, we found limited to uncertain effects on general quality of care indicators such as providers conducting background or physical assessments, or counselling patients. P4P probably has limited to no negative distorting unintended effects, however these were assessed in a minority of studies. For secondary effects, we note mixed effects on health worker variables, such as motivation. The evidence suggests the intervention may increase managerial autonomy, but have limited effects on quality of management or governance in general. Equity effects are also uncertain: when assessed against a pure control, P4P appears may have largely beneficial redistributive effects, but when assessed against a comparator the evidence appears mixed. Effects on user fees are also unclear. Findings of sub-group analyses: Based on intervention descriptions provided in reviewed documents, we classified the various designs schemes used and explored variation in effect by scheme design. Performance based contracting and results-based aid appeared to yield the greatest positive effects upon outcomes overall. However, we note that these scheme designs were used in a minority of schemes and studies, so the effects observed may be spurious. Overall, schemes adjusting both for quality of service as well as rewarding equitable delivery of services appeared to perform best, particularly in relation to service utilization outcomes. Similarly, schemes employing payments per output with a quality adjustment, or combining a payment per output and target payment, appeared to outperform the payment per output and target payment designs.

Authors' conclusions The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. We have identified mixed effects of P4P schemes on outcomes of interest and further noted high heterogeneity in the types of schemes implemented as well as evaluations conducted. Performance based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g. who receives payments, the magnitude of the incentives, the targets and how they are measured), the amount of additional funding, other ancillary components such as technical support, and contextual factors, including the organisational context in which it is implemented.